HOW TO READ AN EOB
How to Read an
Explanation of Benefits
Below is a description of your Explanation of Benefits (EOB). The numbers
correspond with the numbers on the sample copy of the EOB (see the last
page for an example of an EOB).
1.
Claim Processing Office: this is the location of the claims processing office. You can
write to customer service at this location.
2.
Address: the name and address where the EOB is being mailed.
3.
Customer Service: number to call with questions regarding your claim.
4.
Group Name: the name of your Group (in most cases, this is your employer).
5.
Group Number: the identification number for your Group. Please refer to this
number if you call or write about your claim.
6.
Location Number: the number assigned to your location within the Group.
7.
Location Name: the name or description of the location.
8.Enrollee: the name of the covered employee.
9.
Enrollee ID: employee’s social security number (last 4 digits only) or identification
number. Refer to this ID number if you call or write about your claim.
10. Plan Number: the identification number for your plan of benefits.
11. Paid Date: if a check was issued, the date it was issued.
12. Fraud Statement: if the services shown are incorrect, contact HealthSmart immediately.
13. Claim Number: the unique identification number assigned to this claim. Please refer
to this number if you call or write about this claim.
14.Patient: the name of the individual for whom services were rendered or supplies
were furnished.
15. Patient Acct: number assigned by the service provider.
16.Provider: the name of the person or organization who rendered the service or
provided the medical supplies.
17. Dates of Service: the date(s) on which services were rendered.
18. Procedure Code: the Current Procedural Terminology (CPT) codes listed on the
provider’s bill.
19. Amount Billed: the charge for each service.
HOW TO READ AN EOB
20. Charges Not Covered: charge that is not eligible for benefits under the plan.
21. Remark Code: code relating to the “Charges Not Covered” amount. Also used to
request additional information or provide further explanations of the claim payment.
22. Discount Amount: identifies the savings received from a Preferred Provider
Organization (PPO), if applicable.
23. Discount Code: the corresponding code for negotiated savings. If Discount Code column
is not present, any negotiated savings discount is listed under the Remark Code column.
24. Allowed Amount: maximum allowed charge as determined by your benefit plan after
subtracting Charges Not Covered and the Provider Discount from the Amount Billed.
25. Deductible Amount: the amount of allowed charges that apply to your plan
deductible that must be paid before benefits are payable.
26.Copay: the amount of allowed charges, specified by your plan, that you must pay
before benefits are paid.
27. Covered Amount: eligible charges considered under your plan.
28. Paid At: the percentage of the Covered Amount that will be considered under your
benefit plan.
29. Payment Amount: benefits payable for services provided.
30. Column Totals: the sum of each column.
31. Patient Responsibility: after all benefits have been calculated, this is the amount of
the enrollee’s responsibility for this claim.
32. Other Credits or Adjustments: represents adjustments based upon the benefits of
other health plans or insurance carriers, including Medicare.
33. Total Payment: the sum of the “Payment Amount” column.
34. Remark Code Description: additional explanation of the Remark or Discount Code
will appear in this section.
35. Paid To: individual or organization to whom benefits are paid.
36. Check Number: the unique number assigned to the check.
37. Check Amount: total benefit amount paid on this claim.
38. Plan Status: deductible/out of pocket status for the current year.
39. PPO Information: the name of the Network used, if any, to discount the claim. This
information can also be found at times under the Important Information Tab.
40. Foreign Language Assistance: multilingual contact information will only appear
when applicable.
41. Going Green: HealthSmart offers members the option to receive electronic, paperless
Explanation of Benefit (EOB) notifications.
42. Important Information: statement explaining your entitlement to a review of the
benefit determination on the Explanation of Benefits (EOB). This information varies
according to each plan.
20130712T10
4782
1
Explanation of Benefits
HealthSmart Benefit Solutions
PO Box 12345
Someplace IA 50005-6789
RETAIN FOR TAX PURPOSES
THIS IS NOT A BILL
Forwarding Service Requested
3
**************************SNGLP 630
2 16 1 SP 0.460
JANE SAMPLE
123 MAIN STREET
HOMETOWN IA 50701
1
Participant Information
4
5
6
7
8
9
12 Your cooperation is needed to stop fraud!
If these services were not rendered,
please contact HealthSmart immediately at the number above.
Claim#
Patient:
14
91239999-01
JANE SAMPLE
Dates of Service Proc.
Amount
Code 18 Billed 19
17
Customer Service
Questions for Customer Service, please call
(866)524-7326 between the hours of
8:00 am - 6:00 pm CST
Or visit us at www.healthsmart.com
FFTTADAFAFTDFFAFAAAAFTDAADTFATFFFTTAFFDAAFTDAFATDADTFFDTFADFTATFT
13
15
16
10
11
Group: DRUG GROUP ALLIANCE
OF AMERICA, INC.
Group No.: 2999999
Location No.: 004
Location: HH
Enrollee: JANE SAMPLE
Enrollee Id: ***-**-9999
Plan No.: 04021
Paid Date: 02/22/2014
Patient#: 99123567
Provider: MIDDLE IOWA REGIONAL MEDICAL CTR
Not
Rmk Discount Discount
Allowed
Deductible
Covered20 Code21 Amount 22 Code 23 Amount 24 Amount 25
CG
Co-pay
Covered
Paid
Amount 26 Amount 27 At 28
87086
$37.01
$0.00
$21.22
ECL
$15.79
$0.00
$0.00
$15.79 100%
$15.79
01/18-01/18/2014
87186
$84.00
$0.00
$69.45
ECL
$14.55
$0.00
$0.00
$14.55 100%
$14.55
01/18-01/18/2014
87088
$34.99
$0.00
$21.37
ECL
$13.62
$0.00
$0.00
$13.62 100%
$13.62
$156.00
$0.00
$112.04
$43.96
$0.00
$0.00
$43.96
$43.96
$0.00
$43.96
31
Patient's Responsibility:
$0.00
32 Other Credits or Adjustments
33 Total Payment
Payment Details
34 Rmk/Discount Code
35 Paid To
ECL ACCEL DISCOUNT PATIENT NOT LIABLE
CG FOR BASIS OF DETERMINATION, REFER TO THE SUMMARY PLAN DESCRIPTION
MIDDLE IOWA REGIONAL MED CTR
36 Check No.
00011234
37 Amount
$43.96
Plan Status
$2475.00
$2000.00
$1475.00
$1000.00
39
Payment
Amount 29
01/18-01/18/2014
30 Column Totals
38
J015 [16] 1 of 1
Page 1 of 2
of your $5000.00 Family Out-of-Pocket has been met for 2014
of your $2000.00 Individual Out-of-Pocket has been met for 2014
of your $3000.00 Family Deductible has been met for 2014
of your $1000.00 Individual Deductible has been met for 2014
PPO Information
CRESENT HEALTH SOLUTIONS
40
41
Foreign Language Assistance
Going Green
Did you know you can choose to GO GREEN with our paperless option? Access www.healthsmart.com/healthsmartcustomers/
members.aspx and login to opt out of receiving the paper version on future claims. You will receive an email notification when a
claim has been processed and ready for viewing online. Our web site also provides you the ability to print copies of your EOBs as
needed in a secure environment.
Page 2 of 2
42 Important
Information
Please contact Customer Service at the number shown above if you need assistance understanding this notice or our decision to
deny you a service or coverage. You are entitled to a review of the benefit determination if you do not agree. To obtain a review,
submit your request in writing to the address shown above. You may request the diagnosis and treatment codes (and their meanings)
if needed for your appeal. Your request should include your name and address, Enrollee ID, claim number, the reason for appealing
and any data, documents and comments you would like to have considered. Written requests for review must be mailed or delivered
within the time limit required by your Plan. Please consult your Plan Document for more information about claim review procedures. If
a claim is denied, or partially denied, because of lack of medical necessity or an experimental treatment exclusion, then upon request
internal rules, guidelines, protocol or an explanation of the clinical judgment for determination will be provided without charge. If you
appeal, we will review our decision and provide you with a written determination. If we continue to deny the payment, coverage, or
service requested or you do not receive a timely decision, you may be able to request an external review of your claim by an
independent third party, who will review the denial and issue a final decision. For questions about your appeal rights, this notice, or for
assistance, you can contact New Mexico Public Regulation Commission, Division of Insurance at (888) 427-5772 or at http://
nmprc.state.nm.us/id.htm.